The CanMEDS role of Collaborator: How is it taught and assessed according to faculty and residents?

Abstract

OBJECTIVE:

To explore the perspectives of paediatric residents and faculty regarding how the Collaborator role is taught and assessed.

METHODS:

Using a constructivist grounded theory approach, focus groups at four Canadian universities were conducted. Data were analyzed iteratively for emergent themes.

RESULTS:

Residents reported learning about collaboration through faculty role modelling but did not perceive that it was part of the formal curriculum. Faculty reported that they were not trained in how to effectively model this role. Both groups reported a need for training in conflict management, particularly as it applies to intraprofessional (physician-to-physician) relationships. Finally, the participants asserted that current methods to assess residents on their performance as collaborators are suboptimal.

CONCLUSIONS:

The Collaborator role should be a formal part of the residency curriculum. Residents need to be better educated with regard to managing conflict and handling intraprofessional relationships. Finally, innovative methods of assessing residents on this non-medical expert role need to be created.

Collaboration is an important aspect of providing comprehensive medical care, avoiding medical error (1) and ensuring job satisfaction among health care providers (2,3). The area of collaboration has been highlighted as an area of focus within physician training by The Royal College of Physicians and Surgeons of Canada (RCPSC), who developed the Canadian Medical Education Directives for Specialists (CanMEDS) roles in 1996 and subsequently revised them in 2005 (4). CanMEDS is only one of several frameworks of essential physician competencies for guiding medical education (5), but it is the most widely used, having been adopted by 16 countries to date (6). It includes seven areas of competency expected for physicians: Medical Expert, Communicator, Collaborator, Health Advocate, Manager, Scholar and Professional.

The RCPSC defines a Collaborator as one who can “effectively work within a healthcare team to achieve optimal patient care” (4). This is critically important because physicians work in partnership with others who are involved in the care of their patients, including other physicians, allied health professionals and the patients’ family. The RCPSC stipulates that physicians who achieve competency in this role are able to participate effectively and appropriately in an interprofessional health care team, and effectively work with other health professionals to prevent, negotiate and resolve interprofessional conflict (4).

There are some roles, such as Medical Expert, that can be more easily assessed using traditional, psychometric methods (7). In contrast, some of the other roles, such as Health Advocate, Collaborator and Manager, are more difficult to assess (8–10). For example, in a survey conducted by the RCPSC, faculty reported that the most difficult roles to teach and assess were Manager and Health Advocate (11). A study by Verma et al (8) explored resident and faculty perceptions of the Health Advocate role and found many barriers to the teaching and assessment of residents in this role.

There have been national faculty development workshops and a RCPSC ‘Train-the-Trainer’ course on the Collaborator to educate faculty about how to teach this role. Interprofessional care and education in some ways overlap with the Collaborator role and there is robust literature in those areas (12–15). From these studies, we can learn that health care professional students value interprofessional education (IPE) and that students prefer it to be offered in a small-group, interactive format (12). It has been reported that teachers often feel unprepared for facilitating inter-professional groups of medical, nursing and dental students in seminar discussions (16). Finally, there are key factors to be aware of in organizing the format in which IPE is offered and the training of instructors who are providing the IPE to maximize the chance for success (14). Physicians in training may also learn about collaboration from staff physicians and in other non-IPE venues. Currently, there are no studies that specifically explore the CanMEDS role of Collaborator in physician training. Given this paucity of research, the aim of the present study was to explore the perspectives of paediatric residents and faculty about how the Collaborator role is taught and assessed.

METHODS

In the present study, a constructivist grounded theory approach was used (17). Grounded theory is useful in situations in which the research question involves social experiences and where the research aim is to explain a process, not to test or verify existing theory and not to arrive at an absolute truth (18).

The data were gathered by conducting focus groups for residents and faculty at four Canadian paediatric postgraduate training sites, namely, the University of Toronto (Toronto, Ontario), the University of Ottawa (Ottawa, Ontario), the University of Calgary (Calgary, Alberta) and the University of Manitoba (Winnipeg, Manitoba). Focus groups were used rather than other means of data collection, such as interviews, because of the synergistic potential that is generated by focus group discussion (19). These four sites were chosen because their heterogenous sizes and geographical locations were representative of the total 17 programs offering paediatric training across Canada. Sampling was continued (ie, conducting focus groups) until saturation was reached (the point at which the ongoing analysis of new data does not produce any new insights relevant to the emergent theory [18]).

Focus groups were conducted with general paediatrics residents who were in the first four years of training and, separately, for paediatric faculty. To be included, faculty members had to spend more than two months per year working clinically with residents. The goal was to include six to eight participants in each focus group, which was based on literature indicating that this number of participants function well in an effective group discussion, allowing adequate input from each member (20,21). All of the eligible residents and faculty were contacted by e-mail by the research assistant; those who agreed to participate did so on a voluntary basis.

The focus group script was prepared based on a review of the literature regarding the Collaborator role and the teaching and assessment of other CanMEDS roles. The initial questions were open ended. The original questions are listed in Table 1. After the first focus group, the script was refined based on what had been learned from the initial analysis. The script continued to be iteratively refined during the data gathering process to better understand the themes that were emerging.

TABLE 1.

Questions used during focus groups for residents and faculty

Questions in resident focus group	Questions in faculty focus group
To what extent is the CanMEDS role of collaborator taught as part of your residency training? How is it taught?	In what ways, if any, do you teach the CanMEDS role of collaborator to your residents?
To what extent is this role modeled by your staff person? In what ways?	What type of instruction have you had about teaching the role of the collaborator to residents?
Are you exposed to any models of intra-professional collaboration (between doctors)?	How do you model this role for your residents during the course of your work? Are you able to model both inter- and intra-professional collaboration? (Inter- is between physicians and other allied healthcare professionals; intra- is between physicians)
How important is it to learn about the role of collaborator as part of residency training?	In what ways do you have the opportunity to witness your residents serving in this role? Who else observes the residents in this role?
Do you receive feedback (ie, more informal) or an assessment on your performance as a collaborator?	By what methods do you assess residents with regard to their performance as collaborators? How do you feel about your abilities to assess the residents in this role?
Who assesses you? Are there others who could offer assessment or feedback on your performance as a collaborator?	How could the assessment be structured so as to be more meaningful for you as a method of providing feedback and constructive criticism?
How helpful is this assessment to you? How could the assessment be structured so as to be more meaningful and helpful to you?	What do you think about your own abilities as a collaborator?
In what ways, if any, have you changed your way of practicing, based on feedback that you received about your performance as a collaborator?	How important is it to teach the role of collaborator as part of residency training?

Each focus group was conducted over an hour-long time period and was facilitated by a trained research assistant. To avoid a situation in which the research assistant could potentially have any influence on the careers of the participants in the future, the research assistant was not a paediatrician and had no previous affiliations with the faculty or residents. All sessions were audio-recorded and were transcribed by an external transcriptionist who anonymized the transcripts before being read by members of the research team.

Because the approach was inspired by constructivist grounded theory, the data gathering was conducted using an iterative process of inquiry, alternating inductive cycles of identifying patterns and formulating hypotheses with deductive cycles of hypothesis verification. One investigator (EB) independently analyzed the data, seeking review when needed. Then an independent reviewer (MC) analyzed a sample of the data to establish the trustworthiness of the analysis. This methodology has been described by others (22). The results, consistent with a grounded theory approach, aimed to formulate a framework for understanding the experiences of residents and faculty with the role of Collaborator.

Research ethics approval was obtained at each institution where focus groups were conducted and all participants provided informed consent.

RESULTS

There was one resident focus group and one faculty focus group at each of the four sites, with the exception of Winnipeg, where there were two faculty focus groups to accommodate a high level of interest in participation. The focus groups included 25 faculty and 21 residents (Table 2). Winnipeg was designated at ‘site 1’, Calgary as ‘site 2’, Toronto as ‘site 3’ and Ottawa as ‘site 4’. Three major themes were identified as discussed below:

TABLE 2.

Numbers of participants in each focus group for each site

Site	Residents (n=21)	Faculty (n=25)
Toronto, Ontario	5	4
Winnipeg, Manitoba	6	7 (group 1) + 3 (group 2)
Ottawa, Ontario	5	7
Calgary, Alberta	5	4

Collaborator role: Highly valued but not formally taught

Participants in all eight groups commented about the importance of the Collaborator role in their professional lives. It was highly valued and believed to be a critical factor in physician well-being and job satisfaction. As one resident commented:

It’s also really important for well being at work …when we don’t collaborate well that just ends up being misery and really wears you down and I think it’s really important to our morale at work to be good collaborators.

(site 1, resident)

Despite the value placed on this role, residents said that they did not have any teaching sessions on the role of Collaborator and faculty said that they did not have any training in how to teach it. One faculty member commented:

It is kind of like in medicine…You learn how to do it and then you teach it. You don’t ever learn actually how to teach it

(site 1, faculty)

However, the general consensus was that formal teaching would not be an appropriate way for residents to learn this role. It is currently taught mostly through role modelling by faculty and most participants believed that this was the best method by which to learn about collaboration. The main suggestions for improvement in teaching and learning the Collaborator role were for faculty development in how to model this role and labelling the teaching moment. In other words, residents may not recognize that they are learning about collaboration per se, unless the faculty member talks about the lessons that can be learned in a particular instance within the explicit framework of the CanMEDS role of Collaborator.

Conflict management

Residents and faculty agreed that most physicians recognize the importance of working well as an interprofessional team on a daily basis. Interestingly, many of the physicians discussed times when they had witnessed problems with intraprofessional (physician-to-physician) relationships. The residents indicated that conflicts often occur behind closed doors between faculty members out-of-earshot of the rest of the team. Conflict also arises during nights and weekends when residents are working independently. This point is made in the following resident comments:

There are services who will give you a hassle for calling them in the night. And we haven’t had great teaching [about] what to do about that. I am just scared to call now so I am not going to call if I can avoid it

(site 4, resident)

If you conflict with someone…it would be perceived better... not to have your resident there. They would be like, ‘How dare you talk to me like that in front of so and so’

(site 1, faculty)

The faculty echoed these sentiments. They reported that physicians often disagreed over patient care and that the dispute would escalate, as exemplified in the following comments:

The tendency is…when a medical team comes to give a consult…for everyone’s blood pressure to go up and to get really upset with advice given and then it becomes this big drama scene

(site 3, faculty)

It’s like it’s fair game to criticize other doctors from other teams in a way that you would never try to get away with criticizing someone of another profession

(site 3, faculty)

Both residents and faculty believed that learning conflict negotiation skills was an important part of training in an era of medicine in which there are increasingly more physician subspecialists who need to learn to work well together and to collaborate with the primary care team. The participants also believed that learning appropriate strategies for managing conflict is an important component of achieving competency in the Collaborator role.

Methods of assessment of residents as Collaborators are poor

Despite the fact that assessment methods were not uniform across the four sites, the participants indicated that all of the assessments relied, at least in part, on rating the residents on a numerical scale. In all of the resident and faculty focus groups, there was unanimous agreement that the current assessment system was suboptimal. The residents discussed at length their desire for sincere and meaningful assessments, but believed that they were not getting the feedback that would help them to improve their practice. The residents commented:

[It] is not exactly measurable quantitatively…I think maybe a lot of us are saying that the way that it’s evaluated right now is very, very poor.”

(site 3, resident)

When you sit down with the staff person for feedback…I don’t really pay too much attention to the check boxes; I have actually never read them before

(site 2, resident)

Faculty had a desire to provide residents with honest and constructive assessments but indicated that they did not have the format to do so. In fact, when faculty actually wanted to let the residents know how they were performing as Collaborators, they often relied on informal feedback. They offered this feedback face-to-face and sometimes even ‘in the moment’, which they found to be more meaningful to residents.

There was consistency in the themes that emerged from the focus groups at the four sites. The only exception was that the residents in Winnipeg had attended conflict management workshops and so their comments reflected an appreciation for this curriculum. The residents at other sites expressed a lack of comfort in dealing with conflict and a need for more training in this area.

DISCUSSION

Currently, teaching the role of Collaborator may only be part of the informal curriculum, with faculty implicitly modelling collaborative work. We therefore need to make this a more explicit part of the formal curriculum (23). The participants suggested that this could partially be accomplished, for example, by labelling teaching moments. There also needs to be more faculty training in how to effectively model this role so that faculty feel confident in their abilities to teach these skills to their residents. In addition, our participants pointed out that conflict management often occurs behind closed doors. One solution to this problem proposed by our participants was for faculty to hold debriefing sessions after conflict situations. Residents would learn from the experience and taking time to debrief would demonstrate the importance that faculty place on learning about collaboration and conflict negotiation.

There was a great deal of discussion about how assessments of the Collaborator role could be improved. Residents in the study wanted face-to-face assessments with specific examples of how they collaborated well or poorly. Faculty wanted to provide accurate assessments but were frustrated at not having the proper format to do so. Therefore, the medical education community needs to consider new and innovative ways to assess this holistic role so that both faculty and residents take it seriously and find it beneficial.

There were several limitations to the present study. It was only conducted with paediatric residents and faculty. Therefore, the findings may not be applicable to all other medical subspecialties. Participants were volunteers and, may therefore, represent a group who is more interested in collaboration than the average resident or faculty member. We chose four sites across Canada to collect data. However, we had a relatively small sample and may not have captured the opinions of residents and faculty at all of the Canadian programs. In addition, by conducting focus groups, there may have been valuable ideas that our participants did not want to share in a group discussion. It is possible that they would have shared thoughts on sensitive subjects in a one-on-one interview with a research assistant. Finally, we did not obtain the perspectives of other health care professionals who collaborate with us. It would be an appropriate next step to conduct a qualitative study with this larger group of various health care professionals to gather data on their perspectives.

CONCLUSION

The role of the Collaborator stands out as an important and unique competency because of its effect on the day-to-day lives of physicians and other health care professionals and its impact on patient care. It is critical to train physicians who are successful collaborators in an era in which ‘team medicine’ and ‘interprofessional care’ are being touted as essential components of medical practice. While teaching students to be collaborators may once have been part of the informal curriculum, it has quickly come to the foreground of medical education. Therefore, we must ensure that residents and faculty perceive that this role is being taught and assessed in ways that are effective. The present study contributes to our understanding of the role of the Collaborator and how it is currently taught, learned and assessed. We hope that it may also influence future teaching of residents, faculty development and assessment of this important competency.